Healthcare Provider Details

I. General information

NPI: 1497595540
Provider Name (Legal Business Name): KATRINA LEIGH FASEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 UNIVERSITY PKWY STE 1550
AIKEN SC
29801-6838
US

IV. Provider business mailing address

460 CLEMSON RD
COLUMBIA SC
29229-7925
US

V. Phone/Fax

Practice location:
  • Phone: 803-649-7535
  • Fax:
Mailing address:
  • Phone: 402-840-3351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28972
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: